Demonstrating the processes and outcomes of a rural Community Mental Health Rehabilitation Service: A realist evaluation.

BACKGROUND: As part of significant mental health reform, the Community Mental Health Rehabilitation Service (CMHRS) was implemented in rural South Australia. The CMHRS is a 10-bed mental health residential program offering rehabilitative mental health support to rural residents. AIM: To analyse the CMHRS service delivery model and its impact on recovery outcomes for consumers. METHODS: A mixed method, realist evaluation approach was utilised. A purposive sample of CMHRS staff (n = 6) and consumers (n = 8) were recruited. Consumer recovery was measured using the RAS-DS (on admission and discharge). Participants' perspectives of the service were gained via one staff focus group (n = 6) and individual semi-structured interviews (consumers n = 6; staff n = 2). Pre-post RAS-DS scores were analysed using paired t-tests/Wilcoxon paired-signed rank test, with qualitative data analysed thematically. RESULTS: Significant positive increases in RAS-DS total scores were observed at discharge, supported by the qualitative themes of (re)building relationships and social connections and recovering health and wellbeing. Contextual factors (e.g. staffing) and program mechanisms (e.g. scheduling) impacting on service implementation were identified. CONCLUSION: Maintaining a rehabilitation recovery-focused approach, balanced with an appropriately trained multi-disciplinary team, are vital for maximising positive consumer outcomes. SIGNIFICANCE: This realist evaluation identifies critical factors impacting rural mental health rehabilitation service delivery.

Outcomes following de novo CNI-free immunosuppression after heart transplantation: a single-center experience.

Renal impairment at the time of heart transplantation complicates the choice of subsequent immunosuppressive therapy. Calcineurin (CNI)-free regimens utilizing proliferation signal inhibitors (PSI) may mitigate against nephrotoxicity in this group; however, their effectiveness remains unclear. We present our 7-year experience with de novo CNI-free, PSI-based immunosuppression after heart transplantation. Of the 152 patients transplanted between July 1999 and July 2006, de novo immunosuppression regimens were 49 CNI-free, PSI-based, 88 CNI, 15 combination of CNI+PSI. Pretransplant creatinine clearance improved within 6 months in the PSI group (0.69 +/- 0.34 mL/s vs. 1.00 +/- 0.54 mL/s, p < 0.05) but not the CNI (1.32 +/- 0.54 mL/s vs. 1.36 +/- 0.53 mL/s, p = ns) or CNI+PSI (1.20 +/- 0.24 mL/s vs. 1.20 +/- 0.41 mL/s, p = ns) groups. The PSI group had more episodes of early (

Diagnostic dilemmas and management of fulminant myocarditis.

Myocarditis is commonly a diagnosis of exclusion. We report a case of fulminant myocarditis in a patient with cardiogenic shock in whom the initial diagnosis was unclear. Early supportive care including extracorporeal membrane oxygenation and intra-aortic balloon pump were instituted. Complete recovery of cardiac function was achieved. This case highlights the difficulty in diagnosing myocarditis and the benefits of early intensive support.

Evaluation of the acutely limping child.

A limp may be defined as any asymmetric deviation from a normal gait pattern. The differential diagnosis of a limp includes trauma, infection, neoplasia and inflammatory, congenital, neuromuscular or developmental disorders. Initially, a broad differential diagnosis should be considered to avoid overlooking less common conditions such as diskitis or psoas abscess. In any patient with a complaint of knee or thigh pain, an underlying hip condition should be considered. The patient's age can further narrow the differential diagnosis, because certain disease entities are age-specific. Vigilance is warranted in conditions requiring emergent treatment such as septic hip. The challenge to the family physician is to identify the cause of the limp and determine if further observation or immediate diagnostic work-up is indicated.

Secondary fractures associated with external fixation in pediatric femur fractures.

Sixty-six femur fractures sustained by children ages 4-14 years and treated with external fixation were reviewed retrospectively to assess factors influencing the incidence of refracture. The total rate of secondary fracture was 12% (eight patients) including five recurrent fractures at the original fracture site and three fractures through the pin sites. After removal of the external fixator, five patients refractured at the original fracture site and one patient fractured through a pin tract. Two patients fractured at pin sites while the fixator was still in place. Multivariate linear-regression analysis showed no correlation between the incidence of refracture and fracture pattern, percentage of bone fragment contact after fixator application, type of external fixator, or dynamization. A statistically significant association (p < 0.05) was found between the number of cortices demonstrating bridging callus [on both anteroposterior (AP) and lateral views] at the time of fixator removal and the rate of refracture. Fractures showing fewer than three cortices of bridging callus had a three (33%) in nine rate of refracture, whereas fractures with three or four cortices of bridging callus had a two (4%) of 57 rate of refracture.

Injury to the growth plate after Pemberton osteotomy.

The Pemberton osteotomy involves cutting directly into the iliopubic and ilioischial limbs of the triradiate cartilage of the acetabulum. Complete closure of the triradiate cartilage after this osteotomy has been described in case reports. The present experimental study was performed to determine whether physeal osseous bars formed after Pemberton osteotomy. Eight Pemberton osteotomies were performed in six piglets. The animals were killed, and the acetabula were studied with use of radiography, computed tomography, and histological analysis for evidence of physeal injury. Plain anteroposterior radiographs of the pelvis did not clearly demonstrate the formation of osseous bars. However, Bucholz radiographs, made with the acetabulum placed directly on the cassette, showed osseous bars in three of the four specimens that were studied in this manner. Histological sections of the eight specimens of triradiate cartilage demonstrated five osseous bars in the iliopubic limb and four in the ilioischial limb. In two specimens, there was disruption of the cartilage without osseous bridging. Only two of the eight specimens had normal histological findings in both the iliopubic and the ilioischial limb of the triradiate cartilage.

Surgical treatment of scoliosis in a spinal muscular atrophy population.

Seventy-eight patients were diagnosed with spinal muscular atrophy between 1969 and 1988. Scoliosis developed in 34 of these patients, an incidence of 60%. Thirty-one patients could be retrospectively reviewed by chart review or interview. The average follow-up was 11.5 years. Onset of scoliosis averaged 8.8 years. Twenty-two patients were treated nonsurgically and nine surgically. Patients had improved sitting balance and endurance after surgery. Complications of surgery included loss of correction in one patient, one pseudarthrosis, and one patient who required prolonged ventilatory support. The prolonged survival of patients with spinal muscular atrophy justifies aggressive orthopaedic management of scoliosis to prevent progression of deformity and improve sitting comfort.